<?php
/**
 * Generated DocBlock
 *
 * @package OpenEMR
 * @link    http://www.open-emr.org
 * @author  cfapress <cfapress>
 * @author  Robert Down <robertdown@live.com>
 * @author  Brady Miller <brady.g.miller@gmail.com>
 * @copyright Copyright (c) 2008 cfapress <cfapress>
 * @copyright Copyright (c) 2017 Robert Down <robertdown@live.com>
 * @copyright Copyright (c) 2016 Brady Miller <brady.g.miller@gmail.com>
 * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
 */
?>
<!-- Form created by Nikolai Vitsyn: 2004/01/23  -->
<!--                          Update 2004/01/29  -->
<?php
include_once("../../globals.php");
include_once("$srcdir/api.inc");
formHeader("Form: bronchitis");
$returnurl = 'encounter_top.php';
?>
<html><head>
<?php html_header_show();?>
<SCRIPT LANGUAGE="JavaScript">
<!-- 

   function onset_check (form)   {
        
    var d, s = "Today's date is: "; //Declare variables.
    d = new Date(); //Create Date object.
    s += (d.getMonth() + 1) + "-"; //Get month
    s += d.getDate() + "-"; //Get day
    s += d.getYear(); //Get year.
            
    onset_str = form.bronchitis_date_of_illness.value;
    if (onset_str == "") {
    alert("No valid date into Onset of illness field!!! Enter date as YYYY-MM-DD");
    alert(d);

    return;
      }
    if (onset_str.length != 10) {
     alert("Your date should be 10 characters");
    return;
      }
    alert("OK, Bye!!!");
    return;
   }
</SCRIPT>

<link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
</head>
<body class="body_top">

<form method=post action="<?php echo $rootdir;?>/forms/bronchitis/save.php?mode=new" name="my_form">
<br></br>
<span class="title" ><?php xl('Bronchitis Form', 'e'); ?></span>
<br></br>

<a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php xl('Save', 'e'); ?>]</a>
<br>
<a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" style="color: #483D8B"
 onclick="top.restoreSession()">[<?php xl('Don\'t Save', 'e'); ?>]</a>
<br></br>
<span class="text" ><?php xl('Onset of Illness:', 'e'); ?> </span><input type="entry" name="bronchitis_date_of_illness" value=""></input>
<br></br>

<span class="text" ><?php xl('HPI:', 'e'); ?>:</span><br></br>
<textarea name="bronchitis_hpi" rows="4" cols="67" wrap="virtual name"></textarea>
<br></br>

<table ><th colspan="5"><?php xl('Other Pertinent Symptoms:', 'e'); ?></th>
<tr>
<td width="80" align="right"><?php xl('Fever:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_ops_fever"></input></td>
<td width="100" align="right"><?php xl('Cough:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_ops_cough"></input></td>
<td width="60" align="right"><?php xl('Dizziness:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_ops_dizziness"></input></td>
</tr>
<tr>
<td width="80" align="right"><?php xl('Chest Pain:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_ops_chest_pain"></input></td>
<td width="100" align="right"><?php xl('Dyspnea:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_ops_dyspnea"></input></td>
<td width="60" align="right"><?php xl('Sweating:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_ops_sweating"></input></td>
</tr>
<tr>
<td width="80" align="right"><?php xl('Wheezing:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_ops_wheezing"></input></td>
<td width="100" align="right"><?php xl('Malaise:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_ops_malaise"></input></td>
</tr>
<tr>
<td width="80" align="right"><?php xl('Sputum:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_ops_sputum"></input></td>
<td width="100" align="right"><?php xl('Appearance:', 'e'); ?></td>
<td><input type="text" name="bronchitis_ops_appearance" size="10" value="<?php xl('none', 'e'); ?>"></input></td>
</tr>
</table>

<table>
<tr>
<td width="205" align="right"><?php xl('All Reviewed and Negative:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_ops_all_reviewed"></input></td>
</tr>
</table>
<br></br>


<table >
<tr>
<td width="60"><?php xl('Review of PMH:', 'e'); ?></td>
<td align="right"></td>
<td><input type="checkbox" name="bronchitis_review_of_pmh"></input></td>
<td align="right"><?php xl('Medications:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_review_of_medications"></input></td>
<td align="right"><?php xl('Allergies:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_review_of_allergies"></input></td>
<td align="right"><?php xl('Social History:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_review_of_sh"></input></td>
<td align="right"><?php xl('Family History:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_review_of_fh"></input></td>
</tr>
</table>
<br></br>

<table>
<tr>
<td width="60"><?php xl('TM\'S:', 'e'); ?></td>
<td align="right"><?php xl('Normal Right:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_tms_normal_right"></input></td>
<td align="right"><?php xl('Left:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_tms_normal_left"></input></td>

<td width="80"><?php xl('NARES:', 'e'); ?> </td>
<td align="right"><?php xl('Normal Right', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_nares_normal_right"></input></td>
<td align="right"><?php xl('Left:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_nares_normal_left"></input></td>
</tr>

<tr>
<td width="50"></td>
<td align="right"><?php xl('Thickened Right:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_tms_thickened_right"></input></td>
<td align="right"><?php xl('Left:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_tms_thickened_left"></input></td>

<td width="80"></td>
<td align="right"><?php xl('Swelling Right', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_nares_swelling_right"></input></td>
<td align="right"><?php xl('Left:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_nares_swelling_left"></input></td>
</tr>

<tr>
<td width="50"></td>
<td align="right"><?php xl('A/F Level Right:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_tms_af_level_right"></input></td>
<td align="right"><?php xl('Left:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_tms_af_level_left"></input></td>

<td width="80"></td>
<td align="right"><?php xl('Discharge Right:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_nares_discharge_right"></input></td>
<td align="right"><?php xl('Left:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_nares_discharge_left"></input></td>
</tr>

<tr>
<td width="50"></td>
<td align="right"><?php xl('Retracted Right:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_tms_retracted_right"></input></td>
<td align="right"><?php xl('Left:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_tms_retracted_left"></input></td>
</tr>

<tr>
<td width="50"></td>
<td align="right"><?php xl('Bulging Right:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_tms_bulging_right"></input></td>
<td align="right"><?php xl('Left:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_tms_bulging_left"></input></td>

</tr>

<tr>
<td width="50"></td>
<td align="right"><?php xl('Perforated Right:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_tms_perforated_right"></input></td>
<td align="right"><?php xl('Left:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_tms_perforated_left"></input></td>
</tr>
</table>

<table>
<tr>
<td width="220" align="right"><?php xl('Not Examined:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_tms_nares_not_examined"></input></td>
</tr>
</table>
<br></br>

<table>
<tr>
<td width="90"><?php xl('SINUS TENDERNESS:', 'e'); ?></td>
<td align="right"><?php xl('No Sinus Tenderness:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_no_sinus_tenderness"></input></td>
<td align="right"></td>

<td width="90"><?php xl('OROPHARYNX: ', 'e'); ?></td>
<td align="right"><?php xl('Normal Oropharynx:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_oropharynx_normal"></input></td>
<td align="right"></td>
</tr>

<tr>
<td width="50"></td>
<td align="right"><?php xl('Frontal Right:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_sinus_tenderness_frontal_right"></input></td>
<td align="right"><?php xl('Left:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_sinus_tenderness_frontal_left"></input></td>
<td align="right"><?php xl('Erythema:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_oropharynx_erythema"></input></td>
<td align="right"><?php xl('Exudate:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_oropharynx_exudate"></input></td>
<td align="right"><?php xl('Abcess:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_oropharynx_abcess"></input></td>
<td align="right"><?php xl('Ulcers:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_oropharynx_ulcers"></input></td>
</tr>

<tr>
<td width="50"></td>
<td align="right"><?php xl('Maxillary Right:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_sinus_tenderness_maxillary_right"></input></td>
<td align="right"><?php xl('Left:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_sinus_tenderness_maxillary_left"></input></td>

<td width="120" align="right"><?php xl('Appearance:', 'e'); ?></td>
<td><input type="text" name="bronchitis_oropharynx_appearance" size="10" value="normal"></input></td>
</tr>
</table>

<table>
<tr>
<td width="238" align="right" ><?php xl('Not Examined:', 'e'); ?> </td>
<td><input type="checkbox" name="bronchitis_sinus_tenderness_not_examined"></input></td>
<td width="268" align="right" ><?php xl('Not Examined:', 'e'); ?> </td>
<td><input type="checkbox" name="bronchitis_oropharynx_not_examined"></input></td>
</tr>
</table>
<br></br>

<table>
<tr>
<td width="60"><?php xl('HEART:', 'e');?></td>
<td align="right"><?php xl('laterally displaced PMI:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_heart_pmi"></input></td>
<td align="right"><?php xl('S3:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_heart_s3"></input></td>
<td align="right"><?php xl('S4:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_heart_s4"></input></td>
</tr>
<tr>
<td width="60"></td>
<td align="right"><?php xl('Click:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_heart_click"></input></td>
<td align="right"><?php xl('Rub:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_heart_rub"></input></td>
</tr>
</table>

<table>
<tr>
<td width="60"></td>
<td><?php xl('Murmur:', 'e'); ?></td>
<td><input type="text" name="bronchitis_heart_murmur" size="10" value="none"></input></td>
<td><?php xl('Grade:', 'e'); ?></td>
<td><input type="text" name="bronchitis_heart_grade" size="10" value="n/a"></input></td>
<td><?php xl('Location:', 'e'); ?></td>
<td><input type="text" name="bronchitis_heart_location" size="10" value="n/a"></input></td>
</tr>
</table>

<table>
<tr>
<td width="203" align="right" ><?php xl('Normal Cardiac Exam: ', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_heart_normal"></input></td>
<td width="93" align="right"><?php xl('Not Examined:', 'e'); ?> </td>
<td><input type="checkbox" name="bronchitis_heart_not_examined"></input></td>
</tr>
</table>
<br></br>

<table>
<tr>
<td width="60"><?php xl('LUNGS:', 'e'); ?></td>
<td width="106"><?php xl('Breath Sounds:', 'e'); ?></td>
<td align="right"> <?php xl('normal:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_bs_normal"></input></td>
<td align="right"><?php xl('reduced:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_bs_reduced"></input></td>
<td align="right"><?php xl('increased:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_bs_increased"></input></td>
</tr>

<tr>
<td width="60"></td>
<td><?php xl('Crackles:', 'e'); ?></td>
<td align="right"><?php xl('LLL:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_crackles_lll"></input></td>
<td align="right"><?php xl('RLL:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_crackles_rll"></input></td>
<td align="right"><?php xl('Bilateral:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_crackles_bll"></input></td>
</tr>

<tr>
<td width="60"></td>
<td><?php xl('Rubs:', 'e'); ?></td>
<td align="right"><?php xl('LLL:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_rubs_lll"></input></td>
<td align="right"><?php xl('RLL:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_rubs_rll"></input></td>
<td align="right"><?php xl('Bilateral:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_rubs_bll"></input></td>
</tr>

<tr>
<td width="60"></td>
<td><?php xl('Wheezes:', 'e'); ?></td>
<td align="right"><?php xl('LLL:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_wheezes_lll"></input></td>
<td align="right"><?php xl('RLL:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_wheezes_rll"></input></td>
<td align="right"><?php xl('Bilateral:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_wheezes_bll"></input></td>
<td align="right"><?php xl('Diffuse:', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_wheezes_dll"></input></td>
</tr>
</table>

<table>
<tr>
<td width="218" align="right" ><?php xl('Normal Lung Exam: ', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_normal_exam"></input></td>
<td width="140" align="right" ><?php xl('Not Examined: ', 'e'); ?></td>
<td><input type="checkbox" name="bronchitis_lungs_not_examined"></input></td>
</tr>
</table>
<br></br>

<span class="text" ><?php xl('Diagnostic Tests:', 'e'); ?></span><br></br>
<textarea name="bronchitis_diagnostic_tests" rows="4" cols="67" wrap="virtual name"></textarea>
<br></br>

<span class="text" ><?php xl('Diagnosis:', 'e'); ?> </span>
<table><tr>
   <td>
   <select name="diagnosis1_bronchitis_form" >
      <option value="None"><?php xl('None', 'e'); ?></option>
      <option value="465.9, URI"><?php xl('465.9, URI', 'e'); ?></option>
      <option value="466.0, Bronchitis, Acute NOS"><?php xl('466.0, Bronchitis, Acute NOS', 'e'); ?></option>
      <option value="493.92, Astma, Acute Exac."><?php xl('493.92, Asthma, Acute Exac.', 'e'); ?></option>
      <option value="491.8, Bronchitis, Chronic"><?php xl('491.8, Bronchitis, Chronic', 'e'); ?></option>
      <option value="496.0, COPD"><?php xl('496.0, COPD', 'e'); ?></option>
      <option value="491.21,COPD Exacerbation"><?php xl('491.21, COPD Exacerbation', 'e'); ?></option>
      <option value="486.0, Pneumonia, Acute"><?php xl('486.0, Pneumonia, Acute', 'e'); ?></option>
      <option value="519.7, Bronchospasm"><?php xl('519.7, Bronchospasm', 'e'); ?></option>
      <br><br>
   </select>
   </td>
</tr>
<tr>
   <td>
   <select name="diagnosis2_bronchitis_form">
      <option value="None"><?php xl('None', 'e'); ?></option>
      <option value="465.9, URI"><?php xl('465.9, URI', 'e'); ?></option>
      <option value="466.0, Bronchitis, Acute NOS"><?php xl('466.0, Bronchitis, Acute NOS', 'e'); ?></option>
      <option value="493.92, Asthma, Acute Exac."><?php xl('493.92, Asthma, Acute Exac.', 'e'); ?></option>
      <option value="491.8, Bronchitis, Chronic"><?php xl('491.8, Bronchitis, Chronic', 'e'); ?></option>
      <option value="496.0, COPD"><?php xl('496.0, COPD', 'e'); ?></option>
      <option value="491.21,COPD Exacerbation"><?php xl('491.21, COPD Exacerbation', 'e'); ?></option>
      <option value="486.0, Pneumonia, Acute"><?php xl('486.0, Pneumonia, Acute', 'e'); ?></option>
      <option value="519.7, Bronchospasm"><?php xl('519.7, Bronchospasm', 'e'); ?></option>
      <br><br>
   </select>
   </td>
</tr>   
<tr>
   <td>
   <select name="diagnosis3_bronchitis_form">
      <option value="None"><?php xl('None', 'e'); ?></option>
      <option value="465.9, URI"><?php xl('465.9, URI', 'e'); ?></option>
      <option value="466.0, Bronchitis, Acute NOS"><?php xl('466.0, Bronchitis, Acute NOS', 'e'); ?></option>
      <option value="493.92, Asthma, Acute Exac."><?php xl('493.92, Asthma, Acute Exac.', 'e'); ?></option>
      <option value="491.8, Bronchitis, Chronic"><?php xl('491.8, Bronchitis, Chronic', 'e'); ?></option>
      <option value="496.0, COPD"><?php xl('496.0, COPD', 'e'); ?></option>
      <option value="491.21,COPD Exacerbation"><?php xl('491.21, COPD Exacerbation', 'e'); ?></option>
      <option value="486.0, Pneumonia, Acute"><?php xl('486.0, Pneumonia, Acute', 'e'); ?></option>
      <option value="519.7, Bronchospasm"><?php xl('519.7, Bronchospasm', 'e'); ?></option>
     <br><br>
   </select>
   </td>
</tr>
<tr>
   <td>
   <select name="diagnosis4_bronchitis_form">
      <option value="None"><?php xl('None', 'e'); ?></option>
      <option value="465.9, URI"><?php xl('465.9, URI', 'e'); ?></option>
      <option value="466.0, Bronchitis, Acute NOS"><?php xl('466.0, Bronchitis, Acute NOS', 'e'); ?></option>
      <option value="493.92, Asthma, Acute Exac."><?php xl('493.92, Asthma, Acute Exac.', 'e'); ?></option>
      <option value="491.8, Bronchitis, Chronic"><?php xl('491.8, Bronchitis, Chronic', 'e'); ?></option>
      <option value="496.0, COPD"><?php xl('496.0, COPD', 'e'); ?></option>
      <option value="491.21,COPD Exacerbation"><?php xl('491.21, COPD Exacerbation', 'e'); ?></option>
      <option value="486.0, Pneumonia, Acute"><?php xl('486.0, Pneumonia, Acute', 'e'); ?></option>
      <option value="519.7, Bronchospasm"><?php xl('519.7, Bronchospasm', 'e'); ?></option>
     <br><br>
   </select>
   </td>
</tr>       
<table>   
<br></br>

<span class="text" ><?php xl('Additional Diagnosis:', 'e'); ?> </span><br></br>
<textarea name="bronchitis_additional_diagnosis" rows="4" cols="67" wrap="virtual name"></textarea>
<br></br>

<span class="text" ><?php xl('Treatment:', 'e'); ?> </span><br></br>
<textarea name="bronchitis_treatment" rows="4" cols="67" wrap="virtual name"></textarea>

<br></br>
<input type="Button" value="<?php xl('Check Input Data', 'e'); ?>" style="color: #483D8B" onClick = "onset_check(my_form)"<br> 
<br>
<a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php xl('Save', 'e'); ?>]</a>
<br>
<a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" style="color: #483D8B"
 onclick="top.restoreSession()">[<?php xl('Don\'t Save', 'e'); ?>]</a>
</form>

<?php
formFooter();
?>
